ESPEN Congress Madrid 2018

Dysglycaemia In Acute Patients With Nutritional Therapy

Diabetes-Specific FeedsM. Karipidou (GR)

Dysglycaemia in acute patients with nutritional therapy

Diabetes specific feeds

Melina S. Karipidou, MSc

Clinical Dietitian Nutritionist

Harokopio University of Athens, Greece

School of Health Science & EducationDepartment of Nutrition & Dietetics

mkaripidou@nutridiet.gr

I have no relevant conflict of interest to disclose

To understand:

the characteristics of diabetes specific formulas (DFs) andtheir differences with standard formulas (SF)

the indications and benefits of their use

the evidence behind this

how to choose the most appropriate formula for the patient

Learning Objectives

Standard FormulasVS

Diabetes formulas

Composition Standard Formula Diabetes Formula

Amount of carbohydrate Higher (>50% TE*) Lower (<50% TE)

Type of carbohydrate Simple Complex slowly digestible blend

Glycemic load/index Higher Lower

Amount of fat Lower (~30% TE) Higher (>30% TE)

Type of fat LCT MUFA, n-3

Amount of fiber Low or no Higher

Type of fiber - Soluble, prebiotic

Amount of protein 15-20% 15-25 %

Type of protein Milk Soy

*TE: Total Energy

Standard Vs Diabetes Formulas

Type of CHOSFs: Corn maltodextrin, corn syrup solids, short-chain fructo-oligosaccharidesDFs: Complex slowly digestible CHO blend: Non-hydrolyzed starches, modifiedmaltodextrins, fructose, polyols (maltitol), slowly digested carbohydrates (isomaltulose,sucromalt)

Type of fiberDFs contain high or exclusive proportion of fermentable(soluble) fibers, prebiotic, soy & oat fiber.Controversial: the effect of the use of high fiber formulas inpostprandial glycemic response

Ojo & Brooke. Nutrients, 2014 Nov; 6(11): 514232nd ESPEN Congress in Nice

Standard Vs Diabetes FormulasCarbohydrate – Fiber – Glycemic Index

FructoseControversial issue+ Low GI (~19)+ Sweetening power- ↑ triglycerides- ↑ LDL cholesterol

Some DFs contain ~20% of the total CHO intakeOther formulas do not contain fructose (recentformulas)

Parks et al. Am J Clin Nutr 2000 Feb;71(2):41Elia et al. Diabetes Care 2005 Sep;28(9):2267

Standard Vs Diabetes FormulasCarbohydrate – Fiber – Glycemic Index

Hofman et al.Asia Pac J Clin Nutr, 2006; 15(3): 412

• Randomized, double blinded, crossover study

• 12 products• 14 healthy volunteers

DFs had significant (P=0.004) lower GI (average ± SEM: 19.4±1.8) than standard formulas (42.1 ± 5.9)

Standard Vs Diabetes FormulasCarbohydrate – Fiber – Glycemic Index

Increased percentage of MUFAs to the detriment of CHO↓ postprandial glycemic response↓ blood glucose levels & variabilityMUFA + n-3: + cardiovascular effects- Delayed gastric emptying- Greater volumes of formula

DFs primarily contain soy protein vs milk caseinImprove insulin sensitivity & fasting glucose concentrations

Shao et al. JPEN 2018 Jul; 42(5): 926

Standard Vs Diabetes FormulasFat - Protein

Recommendations

Based on this available evidence, the ESPEN expert group endorses the utilization of DFs for nutritional support of people with conditions such as

diabetes, obesity or metabolic stress resulting from critical illness or surgery.

DFs have many of the following ingredients in common:i. lower CHO content than SFsii. higher proportion of complex carbohydrates that are slowly

digestible to reduce blood glucose spikingiii. modified maltodextrin, starch, fructose, isomaltulose, and

sucromalt, rather than the maltodextrin, starch, and sucrosefound in SFs

iv. fat content enriched in unsaturated fatty acids, especiallymonounsaturated fatty acids, in higher proportion than in SFs

v. fiber content higher than in SFs

Barazzoni et al. Clin Nutr 2017 Apr; 36 (2): 355-363

Additional randomized controlled studies are desirable to identifyoptimal formula composition.Further studies should address the potential metabolic impact ofhigher utilization of lipid substrates for energy provision.

Barazzoni et al. Clin Nutr. 2017 Apr; 36 (2): 355-363

Regarding enteral nutritionaltherapy, diabetes-specific formulasappear to be superior to standardformulas in controlling post-prandial glucose, HbA1c, and theinsulin response (Ojo & Brooke.Nutrients, 2014 Nov; 6(11): 5142).

Evidence-based recommendations and expert consensus on enteral nutrition in the adult

patient with DM or hyperglycemia8 specialists in endocrinology, nutrition, dieteticsSpanish Society of Endocrinology and Nutrition (SEEN)Spanish Society on Enteral & Parenteral Nutrition (SENPE)

In subjects with diabetes or stress hyperglycemiatreated with EN we suggest use DFs (especially inhome enteral nutrition support) rather than SFs.

Sanz-Paris et al, Nutrition 2017 Sep; 41: 58-67

Only weak grade of recommendation was reached.Further research is needed to allow recommenda-tions with higher levels of evidence. Despite the highincidence of DM and SH in patients who arecandidates for enteral feeding, there are still manygaps of knowledge

Evidence behind recommendations

• Meta-analysis: 23 studies, 784 patients (19 RCTs, 3 CCTs, and 1 CT)

• 16: T2DM, 4: T1DM• 16: Oral, 7: Tube• 16: <24h, 7: 6 days – 3 months

Short- and long-term use of DFs asoral supplements and tube feeds areassociated with improved glycemiccontrol compared to SF.

Patients with T2DM on EN 3 studies compared DSF with SF 1 study compared slowly digested

carbohydrate formula with DSF andstandard formula

1 study compared DSF with 50%calories provided by fat and diabetesspecific enteral formula with 34%calories provided by fat

DFs was more effective to patients withdiabetes on enteral feed in controlling glucoseprofiles including postprandial glucose, HbA1cand insulinemic response.

Studies Limitations

Consist of small sample-size, high drop out rates.

Consist of single-meal investigations that did not examine clinical outcomes.

Conducted in outpatient settings, limiting their application to hospitalizedpatients.

The trials used glycemic or lipid control as their primary outcomes. They didnot detect differences in morbidity and/or mortality.

The impact on glycemic and lipid control was inconclusive.

Studies Limitations

McClave et al. JPEN J Parenter Enteral Nutr 2016 Feb; 40(2):159-211; Mesejo et al. Clin Nutr 2003 Jun; 22(3): 295

Short-term durationHeterogeneous patient populations (combinations of DM1, DM2 versusstress induced hyperglycemia)Did not examine clinical outcomes (length of ICU stay, mechanicalventilation, mortality, infectious or digestive complications, or analyticaldata)Few studies of long-term EN treatment in diabetic patients and even feweron hyperglycemic critically ill patients

Sanz-Paris et al, Nutrition 2017 Sep; 41: 58-67; Hise & Fuhman. Pract Gastroenterol 2009:20-36

Studies Limitations

Distinguish between:

Patient groups: T1DM, T2DM, SH, Obesity/Metabolic syndrome

Medical treatment: Oral antidiabetics and/or insulin

Mode of feeding: Oral or tube, continuous or intermittent administration

Setting: hospitalization, ICU setting, home

Long term studies

Other criteria: body weight (obesity, overweight, malnutrition, etc.), type ofdisease (neurological, oncological, critically ill disorders, etc.), presence orabsence of gastroparesis.

Further research is needed in this area to allow recommendations with higher levels of evidence and grade of recommendation.

Future Research

Although evidence of sufficient quality is not always available, mostpublications suggest the use of DFs, which facilitate the achievement ofmetabolic goals in the patient with hyperglycemia or DM.

More well designed and long term trials should be conducted.

Take Home Message

Barazzoni R, Deutz NEP, et al. Carbohydrates and insulin resistance in clinical nutrition: Recommendationsfrom the ESPEN expert group. Clin Nutr. 2017 Apr; 36 (2): 355-363.

Elia M, Ceriello A, et al. Enteral nutritional support and use of diabetes-specific formulas for patients withdiabetes: a systematic review and meta-analysis. Diabetes Care 2005 Sep; 28 (9): 2267-2279.

McClave S, Taylor B, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in theAdult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteraland Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016 Feb;40(2):159-211.

Ojo O & Brooke J. Evaluation of the role of enteral nutrition in managing patients with diabetes: asystematic review. Nutrients 2014 Nov 18;6(11): 5142-52.

Sanz-Paris Α, Álvarez Hernández J, et al. Evidence based recommendations and expert consensus on enteralnutrition in the adult patient with diabetes mellitus or hyperglycemia. Nutrition 2017 Sep; 41: 58-67.

For Further Reading

Thank you very much!

Boat water reflectionIthaca, GreeceShot: Nasos Kountourakis